The impact of exercise therapy and abdominal binding in the management of diastasis recti abdominis in the early post-partum period: a pilot randomized controlled trial.

Purpose: To explore the feasibility of two physiotherapy interventions for the management of diastasis recti abdominis (DrA): abdominal binding and targeting trunk exercises.Methods: A pilot randomized controlled trial (RCT) design was used to compare the effectiveness of exercise therapy and/or abdominal binding to no intervention on thirty-two primiparous women who presented with DrA in the early post-partum period. Feasibility was determined based on study recruitment, compliance, and attrition rates as well as through computation of treatment effect sizes associated with each intervention compared to no intervention. Outcomes included inter-rectus distance measured using ultrasound, body image, pain, urogynecological symptoms, and function measured using questionnaires, and trunk flexion strength and endurance measured using clinical tests.Results: The recruitment rate was 3 participants/month. Intervention adherence rates were >50% and the attrition rate was 16%. After 6 months, positive effects (Cohen's d (d) = 0.2-0.5) on body image were observed in both the abdominal binding alone and combination therapy groups. A positive effect on trunk flexion strength (d = 0.7) was observed in the combination therapy group.Conclusion: The effect sizes suggest that physiotherapy interventions can positively impact body image and trunk flexion strength. While a clinical trial investigating these interventions is feasible, further preliminary investigation is recommended.

Reliability and Feasibility of Extended Field of View Ultrasound Imaging Techniques for Measuring the Limb Muscle Cross-Sectional Area.

Purpose: Panoramic ultrasound imaging (pUSI) is an extended field of view (FOV) imaging technique that enables visualization of larger muscles; however, it is not available in all ultrasound systems. Using an acoustic standoff pad that is compatible with any ultrasound system may be an alternative method to increase FOV, but it has not been used to evaluate limb muscles. The purpose of this study was to evaluate the reliability and feasibility of using pUSI and an acoustic standoff pad to measure the limb muscle cross-sectional area (mCSA). Method: A cross-sectional study was conducted. Using pUSI and an acoustic standoff pad, we obtained B-mode ultrasound images of the rectus femoris, biceps brachii, and lateral gastrocnemius muscles of 26 healthy participants on two occasions 7-10 days apart. The agreement between the two methods was determined using intra-class correlation coefficients (ICCs) and Bland-Altman plots. Test-retest reliability was assessed using ICCs and standard error of measurement (SEM). The feasibility of acquiring and analyzing the images was evaluated using a Likert scale. Results: The acoustic standoff pad and pUSI demonstrated strong agreement (ICC[3,3] > 0.85); however, the mCSAs were different (p < 0.05). Test-retest reliability for each technique was high for all muscles (ICC[3,3] > 0.85; SEM = 0.6-1.5 cm2). Image acquisition was highly feasible, but there were some limitations in analyzing the images. Conclusions: pUSI and an acoustic standoff pad are two reliable techniques for measuring mCSA, but the measurements are not directly comparable. Future studies should evaluate the accuracy of the acoustic standoff pad compared with gold-standard methods.

Objectif : l'imagerie panoramique (IP) est une technique à champ étendu (CÉ) qui permet de visualiser les grands muscles, mais qui n'est pas offerte dans tous les systèmes d'échographie. Un panneau acoustique autonome compatible avec les autres systémes d'échographie peut être utilisé pour accroître l'étendue du champ, mais il n'a pas été utilisé pour évaluer les muscles des membres. La présente étude visait à évaluer la fiabilité de l'IP et la faisabilité de l'utiliser comme panneau acoustique autonome pour mesurer la surface transversale du muscle (STM) du membre. Méthodologie : les chercheurs ont réalisé une étude transversale. Ils ont obtenu des images d'échographie en mode B du muscle droit antérieur de la cuisse, du biceps brachial et des muscles gastrocnémiens latéraux à l'aide de l'IP et d'un panneau acoustique autonome chez 26 sujets en santé à deux reprises (à sept à dix jours d'écart). Ils ont établi la concordance entre les deux méthodes à l'aide des coefficients de corrélation intraclasse (CCI) et des courbes de Bland-Altman. Ils ont évalué la fiabilité test-retest à l'aide des CCI et de l'écart-type de mesure standard (ÉTM). Ils ont évalué la faisabilité d'acquérir et d'analyser les images à l'aide de l'échelle de Likert. Résultats : Le panneau acoustique autonome et l'IP présentaient une forte concordance (CCI[3,3] > 0,85), mais les STM étaient différentes (p < 0,05). La fiabilité test-retest de chaque technique était élevée pour tous les muscles (CCI[3,3] > 0,85; ÉTM = 0,6 à 1,5 cm2). Il était hautement faisable d'acquérir les images, mais il y avait certaines limites à les analyser. Conclusions : Un IP et un panneau acoustique autonome sont deux techniques fiables pour mesurer la STM, mais les mesures ne sont pas directement comparables. De futures études devront évaluer la précision du panneau acoustique autonome par rapport aux méthodes de référence.

Influence of Ultrasound Transducer Tilt in the Cranial and Caudal Directions on Measurements of Inter-Rectus Distance in Parous Women.

Purpose: An increased inter-rectus distance (IRD) can persist after a pregnancy and may be associated with lumbopelvic dysfunction. Ultrasound imaging (USI) is currently the gold standard for measuring IRD; however, no study has explored the need to standardize the transducer angle during these evaluations. The purpose of this study was to determine whether the angle of the ultrasound transducer relative to the underlying abdominal wall has an effect on measurements of IRD in parous women. Method: Ultrasound images of the linea alba (LA) were captured from 15 women, at rest and during a head lift, beginning with images acquired perpendicular to the LA at the midline, then tilted in 5° increments to 15° in both the cranial and the caudal directions. Repeated-measures analyses of variance were used to test for systematic differences in IRD measurements among the transducer angles in both the rest and the head-lift conditions. An α of 0.05 was used for all tests. Results: No significant effect of transducer angle was found in IRD measurements acquired with participants at rest (F2.24,31.3=1.814; p=0.18) or during a head lift (F3.15,44.1=1.315; p=0.28). Conclusion: When using USI, cranial or caudal tilt errors in transducer angle do not appear to pose a problem when measuring IRD.

Objectif : une diastase des grands droits (DGD) peut persister après la grossesse et s'associer à une dysfonction lombo-pelvienne. L'échographie est actuellement la norme pour mesurer la DGD, mais aucune étude n'a porté sur la standardisation de l'angle du transducteur pendant ces évaluations. La présente étude visait à déterminer si l'angle du transducteur échographique par rapport à la paroi abdominale sous-jacente influe sur les mesures de la DGD chez les femmes primipares. Méthodologie : les chercheurs ont utilisé les images échographiques de la ligne blanche (LB) de 15 femmes, au repos et pendant qu'elles soulevaient la tête, à commencer par des images acquises perpendiculairement à la ligne médiane de la LB, puis inclinées par incréments de cinq degrés jusqu'à concurrence de 15 degrés dans une orientation crânienne, puis caudale. Ils ont utilisé les analyses de mesures de variance répétées pour vérifier les différences systématiques entre les mesures de DGD selon les divers angles du transducteur, à la fois au repos et au moment de soulever la tête. Ils ont privilégié un taux alpha de 0,05 pour tous les tests. Résultats : l'angle du transducteur n'avait pas d'effet significatif sur les mesures de la DGD prises chez des participantes au repos (F2,24,31,3=1,814; p=0,18) ou qui soulevaient la tête (F3,15,44,1=1,315; p=0,28). Conclusion : à l'échographie, les erreurs d'inclinaison de l'orientation crânienne ou caudale de l'angle du transducteur ne semblent pas poser problème lors de la mesure de la DGD.

Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period.

Background: Diastasis recti abdominis (DrA) is associated with negative body image, musculoskeletal pain and dysfunction, and perhaps urogynecological complaints. The severity of DrA has traditionally been determined by measuring the interrectus distance (IRD); however, the relationship between IRD and symptoms in women with DrA is unclear. Objective: The objective of the study was to investigate the relationship between IRD and symptom severity in women with DrA in the early postpartum period. Design: This study used a cross-sectional design. Methods: Thirty-two women with DrA were assessed at 3 weeks postpartum. The IRD was measured using ultrasound imaging. Symptom severity was assessed using the Multidimensional Body-Self Relations Questionnaire subscales (body image), visual analog scales (abdominal, low back, and pelvic pain intensity), the Modified Oswestry Index (disability due to low back pain), and the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire (urogynecological dysfunction). Spearman correlation coefficients (ρ) between IRD and each outcome were calculated and tested using 1-tailed significance (adjusted α = .009). Results: The group median IRD was 2.97 cm (interquartile range = 1.65 cm), with the largest IRD in the sample being 7.97 cm. The IRD was significantly correlated with worst abdominal pain in the last 24 hours (ρ = 0.45, P = .005) and with overall body image (ρ = -0.44, P = .006) but not with the other outcomes. Limitations: Women in the sample were primiparous, were in the early (3 weeks) postpartum period, had relatively low body mass indexes (mean = 25.0 kg/m2) considering that they had recently given birth, were all breast-feeding, and had a narrow age range (27-35 years old). These factors limited the generalizability of our results to all women with DrA. Conclusions: This preliminary work suggests that, in the early postpartum period, IRD as a measure of DrA severity is meaningful for body image.

Utilization of non-invasive imaging tools for assessment of peripheral skeletal muscle size and composition in chronic lung disease: A systematic review.

OBJECTIVES: Non-invasive imaging modalities allow for detailed assessment of peripheral skeletal muscle wasting, which is associated with increased morbidity and mortality in chronic lung disease. Given the increased utilization of imaging tools, a systematic review was conducted using PRISMA guidelines to describe the modalities and acquisition techniques used to evaluate skeletal muscle in chronic lung disease and assess the relationships of muscle size and composition with strength, physical performance, structural alterations and clinical outcomes. METHODS: Six electronic databases were searched (inception-May 2017) to identify prospective studies measuring peripheral skeletal muscle size or composition using computed tomography (CT), magnetic resonance imaging/spectroscopy (MRI/MRS), or ultrasound (US) in adult chronic lung disease patients. RESULTS: Fifty-eight articles were included, which utilized: CT (n = 26), MRI/MRS (n = 16) and US (n = 16) in 2254 participants. All studies measured muscle size, predominantly of the lower extremity (n = 53), and only nine assessed muscle composition (i.e. fat infiltration) mainly with CT or MRI/MRS (n = 7). Thigh muscle size had a significant association with strength (r = 0.43-0.83, n = 13/14 studies), 6-min walk distance (r = 0.60-0.62, n = 3/6) and physical activity (r = 0.30-0.82, n = 3). Thigh muscle atrophy was independently associated with increased re-hospitalization (n = 1) and mortality (n = 3). Increased muscle fat infiltration had a moderate association with reduced physical performance partly related to increased anaerobic metabolism, but its prognostic utility was not assessed. CONCLUSION: Imaging modalities are valuable tools for the characterization of skeletal muscle dysfunction in chronic lung disease in clinical and research settings. The use of muscle imaging as a prognostic marker is promising and requires further study.

Inter-Rectus Distance Measurement Using Ultrasound Imaging: Does the Rater Matter?

Purpose: To investigate the interrater reliability of inter-rectus distance (IRD) measured from ultrasound images acquired at rest and during a head-lift task in parous women and to establish the standard error of measurement (SEM) and minimal detectable change (MDC) between two raters. Methods: Two physiotherapists independently acquired ultrasound images of the anterior abdominal wall from 17 parous women and measured IRD at four locations along the linea alba: at the superior border of the umbilicus, at 3 cm and 5 cm above the superior border of the umbilicus, and at 3 cm below the inferior border of the umbilicus. The interrater reliability of the IRD measurements was determined using intra-class correlation coefficients (ICCs). Bland-Altman analyses were used to detect bias between the raters, and SEM and MDC values were established for each measurement site. Results: When the two raters performed their own image acquisition and processing, ICCs(3,5) ranged from 0.72 to 0.91 at rest and from 0.63 to 0.96 during head lift, depending on the anatomical measurement site. Bland-Altman analyses revealed no systematic bias between the raters. SEM values ranged from 0.23 cm to 0.71 cm, and MDC values ranged from 0.64 cm to 1.97 cm. Conclusion: When using ultrasound imaging to measure IRD in women, it is acceptable for different therapists to compare IRDs between patients and within patients over time if IRD is measured above or below the umbilicus. Interrater reliability of IRD measurement is poorest at the level of the superior border of the umbilicus.

Objectif : examiner la fiabilité interévaluateurs de la mesure de la distance entre les deux faisceaux du grand droit, au repos et en contraction, à partir d'échographies prises chez des femmes qui ont eu un enfant, et établir l'erreur type de mesure (ETM) et le changement minimal détectable (CMD) entre deux évaluateurs. Méthodes : deux physiothérapeutes ont obtenu indépendamment des échographies de la paroi abdominale antérieure de 17 femmes et mesuré la distance sur quatre sites le long de la ligne blanche : au bord supérieur de l'ombilic, à 3 cm et à 5 cm au-dessus du bord supérieur de l'ombilic et 3 cm sous le bord inférieur de l'ombilic. La fiabilité interévaluateurs des mesures a été déterminée à l'aide de coefficients de corrélation intraclasse (CCI). Des analyses Bland-Altman ont été réalisées afin de détecter le biais entre les évaluateurs et les valeurs ETM et CMD ont été calculées pour chaque site de mesure. Résultats : lorsque les deux évaluateurs ont obtenu et traité eux-mêmes les images, les CCI(3,5) allaient de 0,72 à 0,91 au repos et de 0,63 à 0,96 en contraction, selon le site de mesure. Les analyses Bland-Altman n'ont révélé aucun biais systématique entre les évaluateurs. Les valeurs ETM allaient de 0,23 cm à 0,71 cm, les valeurs CMD de 0,64 cm à 1,97 cm. Conclusion : lorsqu'on mesure la distance entre les faisceaux du grand droit à partir d'échographies, il est acceptable pour différents thérapeutes de comparer la distance entre patients et au fil du temps pour un même patient si la distance est mesurée au-dessus ou en dessous de l'ombilic. La fiabilité interévaluateurs de la mesure est la plus faible au niveau du bord supérieur du nombril.

Validity of Inter-rectus Distance Measurement in Postpartum Women Using Extended Field-of-View Ultrasound Imaging Techniques.

STUDY DESIGN: Reliability and validity study. OBJECTIVES: To investigate the criterion-related validity and reliability of inter-rectus distance (IRD) measurement using extended field-of-view (FOV) techniques during ultrasound imaging (USI) in parous women. BACKGROUND: Ultrasound imaging is the gold standard for noninvasive IRD measurement in parous women when investigating diastasis recti; however, its use is limited when IRD is large. Extended FOV techniques (panoramic USI or using acoustic standoff pads) allow complete visualization of the linea alba when the IRD is large and conventional imaging is not sufficient; however, the validity of using these techniques has never been investigated. METHODS: Two-dimensional ultrasound images were acquired at the superior umbilical border from 21 women using conventional USI, panoramic USI, and a standoff pad. Five images were captured using each method. Inter-rectus distance was measured offline. Criterion-related validity was investigated using repeated-measures analyses of variance to test for bias, and linear regression models, Pearson correlation coefficients (r), and intraclass correlation coefficients (ICCs) to assess agreement. Standard error of the measurement for each extended FOV technique was calculated. The between-trial reliability of each technique was determined using ICCs. RESULTS: Inter-rectus distance from images acquired using extended FOV techniques did not differ from values acquired using conventional USI (P = .441). Images acquired using extended FOV techniques were highly correlated with those acquired using conventional imaging (r>0.95, P<.0001). The standard error of the measurement of each extended FOV technique was 0.17 to 0.18 cm. The between-trial reliability of all techniques was excellent (ICC(3,1)>0.90). CONCLUSION: Panoramic USI and acoustic standoff pads are valid methods of increasing FOV to measure IRD. In this study, USI measurements were limited to IRDs of less than or equal to 3 finger widths, based on palpation.

Ultrasound Imaging in Postpartum Women With Diastasis Recti: Intrarater Between-Session Reliability.

STUDY DESIGN: Clinimetrics. OBJECTIVES: To investigate the intrarater between-session reliability of inter-rectus distance (IRD) measurement using ultrasound imaging in postpartum women with diastasis recti. BACKGROUND: Diastasis recti, a separation of the rectus abdominis muscles at the linea alba, occurs as a result of pregnancy and is characterized by increased IRD. The measurement of IRD in this population is of interest to determine changes in diastasis recti severity over time, or in response to treatment. Ultrasound imaging has been proposed as a useful tool to measure IRD in women with diastasis recti; however, the consistency of IRD measurement in this population using ultrasound imaging has, to our knowledge, never been investigated. METHODS: Ultrasound imaging was used to measure IRD in 20 women with diastasis recti on 2 different occasions. On each testing occasion, images were acquired at 4 locations along the linea alba while participants remained relaxed and while they performed a head lift to activate the rectus abdominis muscles. Reliability statistics included intraclass correlation coefficients, Bland-Altman analyses, minimum clinically important difference, and standard error of the measurement. RESULTS: Between-session reliability of IRD measurement was high, particularly when measuring IRD at or above the umbilicus, as indicated by intraclass correlation coefficients greater than 0.90 and low standard error of the measurement and minimum clinically important difference values (below 0.17 cm and 0.46 cm, respectively). Reliability coefficients were poorer when measuring IRD below the umbilicus. CONCLUSION: When performed by an experienced investigator, ultrasound imaging is a reliable tool by which to measure IRD in postpartum women who have diastasis recti.

State of the art review: Intravaginal probes for recording electromyography from the pelvic floor muscles.

AIM: To survey commercially available intravaginal probes designed to record electromyography (EMG) from the pelvic floor muscles (PFMs), and to discuss the strengths and limitations of current technology. METHODS: The MEDLINE EMBASE, CINAHL, PEDRO, and Cochrane databases were searched for articles in which intravaginal probes were described as having been used to record EMG from the PFMs. The World Wide Web was also searched using the Google search engine to find devices used to record EMG from the PFMs. Finally, a Canadian distributer of intravaginal probes was contacted to identify intravaginal EMG probes not identified through other methods. The specifications of each probe were determined through the manufacturer or their website, and each device was acquired by the investigators to verify the specifications and electrode configuration. The devices were evaluated against international standards for recording EMG data. RESULTS: Sixteen different models of commercially available intravaginal probes were identified: seven from published research papers, seven using the World Wide Web, and two through communication with a distributer. The probes vary in shape, dimensions, electrode positioning, and electrode configuration, with many designs prone to recording motion artifact, crosstalk, and/or inappropriate EMG signals. CONCLUSION: All commercially available intravaginal probes had deficiencies in their design such as problems with probe geometry, electrode size, location, and/or configuration. Improved intravaginal EMG probes should be developed for use in research and clinical practice.

A differential suction electrode for recording electromyographic activity from the pelvic floor muscles: crosstalk evaluation.

The purpose of this study was to determine whether a differential suction electrode (DSE) probe is less prone to recording crosstalk from the hip adductors or external rotators than the Femiscan™ probe when recording electromyography (EMG) data from the pelvic floor muscles (PFMs). Twenty nulliparous, continent women performed hip adduction and hip external rotation contractions at 25%, 50% and 100% of maximal voluntary effort both while keeping their PFMs relaxed and while contracting their PFMs as strongly as possible. All tasks were performed while DSEs were adhered to the vaginal wall at the level of the pubococcygeus group bilaterally, and also with the Femiscan™ probe in situ. The order of the probes was randomized. For each task, the peak smoothed PFM EMG amplitude was compared between hip forces and probes using a two-way repeated measures analysis of variance (ANOVA) including the interaction between contraction level and probe (α = 0.05). There was a significant contraction level by probe interaction for each task. In most cases the Femiscan™ probe recorded significantly higher PFM EMG activity during hip adduction and external rotation tasks at 25% and 50% MVC compared to what it recorded when the hip musculature remained relaxed, whereas the DSE probe did not. As such, the DSE probe appears to be less susceptible to crosstalk from the hip adductors and external rotators than the Femiscan™ probe at these hip muscle contraction levels. Both probes recorded significantly higher EMG activity when maximal contractions of the hip adductors and external rotators were performed therefore, no conclusion can be made regarding whether the activity recorded from the PFMs during maximal hip adduction and external rotation is the result of crosstalk or co-activation.

Development of a differential suction electrode for improved intravaginal recordings of pelvic floor muscle activity: reliability and motion artifact assessment.

AIM: The purposes of this study were to compare: (i) the reliability of electromyography (EMG) activity recorded from the pelvic floor muscles (PFMs) using a new differential suction electrode (DSE) to the reliability of EMG data recorded using other common electrodes, and (ii) motion artifact contamination of EMG activity recorded from the PFMs using the DSE and the Femiscan™ electrode. METHODS: With the DSE and the Femiscan™ in situ, at two separate sessions, each of 20 participants performed three repetitions of a maximum voluntary contraction (MVC) of their PFMs, and 10 repetitions of a maximal effort cough. With Delsys® electrodes located over the biceps brachii, each participant performed three repetitions of a MVC. Between-trial and between-day reliability were assessed using several methods. Motion artifact was assessed by comparing the proportion of contaminated files recorded by each electrode during coughing. RESULT: The DSE was found to have excellent between-trial reliability, as were the Femiscan™ and Delsys® electrodes. Between-day reliability was good for the DSE, but reliability was higher for the Delsys® electrode and the Femiscan™ electrode. The DSE performed better than the Femiscan™ electrode in terms of motion artifact contamination. CONCLUSIONS: The DSE has excellent between-trial reliability and performs better than the Femiscan™ electrode in terms of motion artifact contamination. It does not perform as well as the Femiscan™ electrode in terms of between-day reliability--a result that is not unexpected given the localized region from which the DSE records activity.